Break a Confidence? Never. Well, Hardly Ever.

Tuesday

May 29, 2007 at 5:40 AM

Today, confidentiality is almost a mantra in medicine, but it is not absolute.

SANDEEP JAUHAR, M.D.

Anyone who has ever worked in a hospital can attest that doctors are purveyors of information: dry facts, clinical data, medical wisdom. When I was an intern, my hospital had a separate computer system for laboratory results, another for vital signs and nursing notes, and another for medical records. Clinical medicine, it seemed then, wasn’t about patient care as much as about data management.

Much of what doctors learn about patients is private and personal, which vastly complicates our enterprise. Doctors have to know how to keep secrets — from insurers, employers, family members, and even, occasionally, the police. I once took care of a business executive who had hired call girls during a weekend drug binge. When he saw a cop in the hallway, he quietly handed me an envelope containing a large amount of white powder. I wasn’t sure what to do with it — was I now an accomplice? — so I threw it away. For the next several hours he eyed me suspiciously, probably wondering whether I had ratted on him. But it never occurred to me to do so.

The duty to keep patient information private is written into the codes of ethics of several medical organizations, and is even in the Hippocratic Oath: “What I may see or hear in the course of the treatment or even outside the treatment in regard to the life of men,” it says, “I will keep to myself.” Such an obligation is necessary to foster openness and honesty, essential for a healthy doctor-patient relationship.

Still, even a cursory walk through the warrens of a hospital would reveal that doctors do sometimes betray confidentiality. We discuss patient information in the elevator. We hash over intimate details in double-occupancy rooms within earshot of neighbors. In 1996, Congress passed privacy legislation that makes it harder, and in some cases illegal, for doctors to reveal patients’ information without explicit permission. Yet such disclosure continues.

Today, confidentiality is almost a mantra in medicine, but it is not absolute. Doctors must disclose private information when it is clearly in the patient’s interest — documenting a drug allergy in the medical record, for example — or when it comes to complying with a court order or a law (as in cases of child abuse). Doctors must also betray confidentiality when it is in the “public interest” (reporting infectious diseases, for example, or to warn potential victims of violence).

But when does public interest trump individual autonomy? It is rarely clear-cut. I once performed a coronary angiogram on a hospital electrician who told me he abused cocaine daily (which no doubt contributed to his severe angina). When I asked a colleague whether I should document this habit in the patient’s chart, or even alert the patient’s — our — employer, he said: “We don’t have to do anything. Remember, first do no harm.”

I never did tell anyone, though I exhorted the patient in the strongest terms to quit using drugs. But I wonder if I did the right thing. What about the risk to the hospital, to other patients, of the man’s addiction?

The World Medical Association states that confidentiality should be breached only when the expected harm of maintaining privacy is believed to be imminent, serious and unavoidable except by unauthorized disclosure. The philosophy behind this point of view is called utilitarianism: achieving the greatest good for the greatest number.

But once in a while the issue gets turned on its head. I once had the unenviable task of informing a 22-year-old man that he was suffering from severe heart failure and would probably need a transplant. His father warned me that his son would be devastated to hear the diagnosis. “It would mean a lot to me if you could tell him he’s going to be all right,” the father told me in the cardiac care unit. “He thinks he’s going to die. Please, he has lost all hope. Please tell him that if he does the things you say, he’s going to be O.K.”

I wasn’t sure what to do, but it was obvious that this young man wasn’t prepared to hear the news I had to present. I went into his room and told him exactly what his father had requested. Over several days, I eased him into the knowledge of his true condition. Doctors have to know how to keep secrets — even, rarely, from patients themselves.

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